6. MANAGER OR MEMBER INFORMATION-REQUIRED: (MUST LIST AT LEAST ONE MANAGER OR MEMBER OF THE LLC.)
ATTACH 81/2 X 11 SHEETS IF NECESSARY.

BUSINESS ADDRESS
RESIDENCE ADDRESS:
NAME TITLE (No. P.O Box)
(No. P.O Box)
IF NONE, MUST STATE “NONE”

7. MANAGEMENT – PLACE A CHECK NEXT TO THE FOLLOWING STATEMENT ONLY IF IT APPLIES

MANAGEMENT OF THE LIMITED LIABILITY COMPANY SHALL BE VESTED IN A MANAGER OR MANAGERS

8. EXECUTION: (SUBJECT TO PENALTY OF FALSE STATEMENT)

DATED THIS DAY OF , 20

NAME OF ORGANIZER SIGNATURE
(PRINT OR TYPE)

AN ANNUAL REPORT WILL BE DUE YEARLY IN THE ANNIVERSARY MONTH THAT THE ENTITY WAS FORMED/REGISTERED AND CAN BE
EASILY FILED ONLINE @ www.concord-sots.ct.gov
CONTACT YOUR TAX ADVISOR OR THE TAXPAYER SERVICE CENTER AT THE DEPARTMENT OF REVENUE SERVICES AS TO ANY
POTENTIAL TAX LIABILITY RELATING TO YOUR BUSINESS, INCLUDING QUESTIONS ABOUT THE BUSINESS ENTITY TAX.
TAX PAYER SERVICE CENTER: (800) 382-9463 OR (860) 297-5962 OR GO TO www.ct.gov/drs

FORM LC-1-1.0
PAGE 2 OF 2
Rev. 1/11/2011

———————– Page 3———————–

INSTRUCTIONS

1. Name of Limited Liability Company-REQUIRED: The name MUST INCLUDE business designation, such as Limited

4. Mailing Address-OPTIONAL: Fill in an address other than the principal business address if you would like the annual

report sent elsewhere.

5. Appointment of statutory agent for process-REQUIRED: THE LIMITED LIABILITY COMPANY MAY NOT BE ITS

OWN AGENT. An individual or entity (other than this LLC) must be appointed to accept legal process, notice or
demand served upon the limited liability company. The agent may be EITHER:

a. Any individual who is a resident of Connecticut, including a manager or member of the LLC.
• An individual must provide the complete street address of his or her business and a Connecticut residence
address.

(If no business address, must state none).
• The agent must sign accepting the appointment.
or

b. One of the following business types, on record with this office, with a Connecticut address:
• A Connecticut corporation, limited liability company, limited liability partnership or statutory trust.
• A foreign corporation, limited liability company, limited liability partnership or statutory trust, which has obtained a

certificate of authority to transact business in Connecticut and has a Connecticut address on file with this office.

• Provide the Connecticut principal office address in the block designated for “Business address”. The agent

must sign accepting the appointment and the person signing on behalf of a business must print his/her

name and title next to his/her signature.

6. Manager or member information-REQUIRED: The limited liability company must list the name, title, business and
residence address of at least one manager or member of the limited liability company. (if no business address, must
state none). Include street number, street, city, state and zip code. (Additional member(s) and manager(s) information

may be included on an attached 8 ½ x 11 sheet.)

7. Management: If the limited liability company is to be managed by its member(s) do not check the box.

8. Execution-REQUIRED: The organizer must print or type his or her full legal name and provide a signature. Note that
the execution is made under the penalties of false statement, certifying that the information provided in the document

is true. *THE LIMITED LIABILITY COMPANY MAY NOT BE ITS OWN ORGANIZER BUT A MANAGER/MEMBER

MAY BE THE ORGANIZER.

.***YOU ARE REQUIRED TO FILE ARTICLES OF DISSOLUTION IF YOU DISSOLVE YOUR BUSINESS. ***

Note: LLC’s may have as many managers/members as they wish. However, only three will be shown on the database.

Additional names will be available by requesting copies of the original filing.